Quantifying Orthotic Correction of Trigonocephaly Using Optical Surface Scanning.

ABSTRACT: Numerous publications describe techniques to measure trigonocephaly caused by metopic synostosis, but they are potentially hazardous for use in acquiring longitudinal data. Optical surface scanning technology can safely yield craniometrics but has not established a practical means for measuring objective morphological changes to trigonocephaly during the practical time constraints of a clinical visit. The purpose of this preliminary study was to evaluate a method for safely and repeatedly measuring frontal angle (FA) using technology available at multiple centers providing treatment with cranial remolding orthoses.Optical scans of infants who underwent endoscopic-assisted minimally-invasive craniectomy for repair of metopic synostosis with cranial remolding were retrospectively analyzed. A novel FA measurement technique "FA30" was developed based on repeatable, geometrically-related surface landmarks approximating the glabella and frontotemporali. Results were compared to a control group and categories of non-synostotic deformity. Inter-rater reliability was assessed for pre- and post-treatment scan measurements among separate clinicians.All trigonocephalic subjects (n = 5) had initial FA30 significantly lower than the control group and other cohorts (P < 0.001). During the course of orthotic cranial remolding following surgical release mean FA30 increased from 121.5° to 138.5° (P < 0.001), approaching the control group mean of 144.4°. Intraclass coefficient calculation showed high reliability (intraclass correlation coefficient: 0.993, 95% confidence interval: 0.957-0.998, P < 0.001), which was supported with Bland-Altman analyses of agreement.Optical surface scanning may provide a safe, accurate, and repeatable means to measure FA. Increase in FA30 demonstrates correction of trigonocephaly. The method presented enables expeditious reporting of treatment progress to the infant's surgeon and parents, and has potential for use in optimizing treatment outcomes at multiple centers.

Multimodality Intraoperative Neurophysiological Monitoring (IONM) During Shoulder Surgeries.

Introduction: The purpose of this study is to identify the advancing role of Intraoperative Neurophysiological Monitoring (IONM) in detecting and preventing nerve injuries during shoulder surgery procedures. Methods: We performed a retrospective analysis of IONM data from ten shoulder procedures. The patients consisted of nine females and one male with ages ranging from 67 to 81 years (median: 74 years). IONM modalities utilized were bilateral Somatosensory Evoked Potentials (SSEP), Transcranial Motor Evoked Potentials (TCeMEP), ipsilateral Electromyogram (EMG) from upper extremity muscles and Train of four (TOF) recordings. Results: A decrease in signals was noted in three patients (30%). Only upper SSEP amplitude decreased in one patient; both upper extremity SSEP and TCeMEP decreased in two patients. Only one patient had poor baseline radial nerve SSEP that improved during the surgery. We performed spontaneous EMG (s-EMG) in all ten patients and successfully recorded triggered (t-EMG) in seven patients (71.4%). In one patient, SSEP and TCeMEP did not improve, and the patient woke up with deficits. Conclusions: In this small series, we were able to identify real-time impending nerve injury. The use of IONM alerted and may have prevented intraoperative nerve injury in 30% of the patients in this series. In one patient, SSEP and TCeMEP did not recover even after the intervention due to severe blood loss. The patient woke up with sensory and motor deficits. The utilization of multimodality IONM can be helpful due to signal changes, therefore minimizing the frequency of nerve injury and deficits.

Reverse shoulder arthroplasty using an implant with a lateral center of rotation: outcomes, complications, and the influence of experience.

Reverse shoulder arthroplasty (RSA) has revolutionized treatment of arthritis and rotator cuff insufficiency and is performed using implants with either a medial or a lateral center of rotation. We conducted a study of the outcomes and the effect of surgeon learning after the first 60 consecutive lateral-center-of-rotation RSAs implanted by a single surgeon unaffiliated with the design team for this particular reverse shoulder prosthesis. At minimum 2-year followup, mean improvements in active forward elevation, abduction, and external rotation were 69°, 55°, and 23°, respectively; mean active internal rotation improved significantly as well (P < .001 for all). Mean Simple Shoulder Test (SST) scores improved from 1.8 (range, 0-6) to 6.9 (range, 0-12) (P < .0001), and mean final American Shoulder and Elbow Surgeons score was 72 (range, 27-100). Final radiographs showed scapular notching in 5 shoulders (11%). Gains in SST scores, active forward elevation, and active abduction were lower for the first 15 cases than for the next 45 cases, and 5 of the 8 reoperations were performed after the first 15 cases. Overall improvements in active motion and self-assessed shoulder function in this series are comparable to those previously reported by the design team. Experience with RSA appears to influence efficacy, but the learning curve may not be as steep as previously reported.

Avoiding health information.

This study investigated why and how individuals avoid health information to support the development of models of uncertainty and information management and offer insights for those dealing with the information and uncertainty inherent to health and illness. Participants from student (n = 507) and community (n = 418) samples reported that they avoided health information to (a) maintain hope or deniability, (b) resist overexposure, (c) accept limits of action, (d) manage flawed information, (e) maintain boundaries, and (f) continue with life/activities. They also reported strategies for avoiding information, including removing or ignoring stimuli (e.g., avoiding people who might provide health advice) and controlling conversations (e.g., withholding information, changing the subject). Results suggest a link between previous experience with serious illness and health information avoidance. Building on uncertainty management theory, this study demonstrated that health information avoidance is situational, relatively common, not necessarily unhealthy, and may be used to accomplish multiple communication goals.

Development of a method for fabricating polypropylene non-articulated dorsiflexion assist ankle foot orthoses with predetermined stiffness.

BACKGROUND: A non-articulated plantarflexion resist ankle foot orthosis (AFO), commonly known as a posterior leaf spring AFO, is indicated for patients with motor impairment to the dorsiflexors. The AFO is often custom molded to a patient's lower limb anatomy and fabricated from polypropylene. There are no established guidelines for fabricating this type of AFO with predetermined stiffness of the ankle region for normal walking speeds. Therefore an AFO may not meet the biomechanical needs of the patient. OBJECTIVES: Quantify the biomechanical ankle stiffness requirement for an individual with complete dorsiflexor impairment and develop a method for fabricating an AFO with ankle stiffness to meet that requirement. STUDY DESIGN: Experimental, bench research. METHODS: The literature on sagittal biomechanics of non-pathological adults was reviewed to derive the stiffness of the ankle during loading response. Computer models of 144 AFOs were created with geometric variations to account for differences in human anthropometrics. Computer-based finite element analysis was employed to determine the stiffness and safety factor of the models. RESULTS: Stiffness of the AFOs ranged from 0.04 to 1.8 Nm/deg. This ample range is expected to account for the stiffness required for most adults with complete dorsiflexor impairment. At 5° deflection the factor of safety (ratio of strength to stress) ranged from 2.8 to 9.1. A computer program was generated that computes AFO stiffness from user-input variables of AFO geometry. The stiffness is compared to a theoretically appropriate stiffness based on the patient mass. The geometric variables can be modified until there is a close match, resulting in AFO design specification that is appropriate for the patient. CONCLUSION: Through validation on human subjects, this method may benefit patient outcomes in clinical practice by avoiding the current uncertainty surrounding AFO performance and reducing the labor and time involved in rectifying a custom AFO post-fabrication. CLINICAL RELEVANCE: This method provides an avenue for improving patient outcomes by avoiding the current uncertainty surrounding non-articulated plantarflexion resist ankle foot orthosis performance. The ability to quantify the biomechanical ankle stiffness requirement for an individual with complete dorsiflexor impairment provides insight into how other AFO types should be designed as well.